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      Rehabilitation Interventions for Unilateral Neglect after Stroke: A Systematic Review from 1997 through 2012

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          Abstract

          A systematic review of the effectiveness of rehabilitation for persons with unilateral neglect (UN) after stroke was conducted by searching the computerized databases from 1997 through 2012. Randomized controlled trials (RCTs) of neglect treatment strategies for stroke patients which used the Behavioral Inattention Test (BIT) as the primary outcome measure were eligible for inclusion. Out of 201 studies initially identified, 12 RCTs covering 277 participants were selected for analysis. All had the same weakness of low power with smaller samples and limitation in the blinding of the design. Prism Adaptation (PA) was the most commonly used intervention while continuous Theta-burst stimulation (cTBS) appeared to be a new approach. Meta-analysis showed that for immediate effects, the BIT conventional subscore had a significant and large mean effect size (ES = 0.76; 95% CI 0.28–1.23; p = 0.002) whereas the BIT total score showed a modestly significant mean ES (ES = 0.55; 95% CI 0.16–0.94; p = 0.006). No significant mean ES in sensitivity analysis was found for long-lasting effects across all BIT outcomes. PA appeared to be the most effective intervention based on the results of pooled analysis. More rigorous studies should be done on repetitive transcranial magnetic stimulation (rTMS) before it can be concluded that it is a promising treatment for UN.

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          Non-invasive brain stimulation: a new strategy to improve neurorehabilitation after stroke?

          Motor impairment resulting from chronic stroke can have extensive physical, psychological, financial, and social implications despite available neurorehabilitative treatments. Recent studies in animals showed that direct epidural stimulation of the primary motor cortex surrounding a small infarct in the lesioned hemisphere (M1(lesioned hemisphere)) elicits improvements in motor function. In human beings, proof of principle studies from different laboratories showed that non-invasive transcranial magnetic stimulation and direct current stimulation that upregulate excitability within M1(lesioned hemisphere) or downregulate excitability in the intact hemisphere (M1(intact hemisphere)) results in improvement in motor function in patients with stroke. Possible mechanisms mediating these effects can include the correction of abnormally persistent interhemispheric inhibitory drive from M1(intact hemisphere) to M1(lesioned hemisphere) in the process of generation of voluntary movements by the paretic hand, a disorder correlated with the magnitude of impairment. In this paper we review these mechanistically oriented interventional approaches. WHAT NEXT?: These findings suggest that transcranial magnetic stimulation and transcranial direct current stimulation could develop into useful adjuvant strategies in neurorehabilitation but have to be further assessed in multicentre clinical trials.
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            The PEDro scale is a valid measure of the methodological quality of clinical trials: a demographic study.

            Does the PEDro scale measure only one construct ie, the methodological quality of clinical trials? What is the hierarchy of items of the PEDro scale from least to most adhered to? Is there any effect of year of publication of trials on item adherence? Are PEDro scale ordinal scores equivalent to interval data? Rasch analysis of two independent samples of 100 clinical trials from the PEDro database scored using the PEDro scale. Both samples of PEDro data showed fit to the Rasch model with no item misfit. The PEDro scale item hierarchy was the same in both samples, ranging from the most adhered to item random allocation, to the least adhered to item therapist blinding. There was no differential item functioning by year of publication. Original PEDro ordinal scores were highly correlated with transformed PEDro interval scores (r = 0.99). The PEDro scale is a valid measure of the methodological quality of clinical trials. It is valid to sum PEDro scale item scores to obtain a total score that can be treated as interval level measurement and subjected to parametric statistical analysis.
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              Spatial attention and neglect: parietal, frontal and cingulate contributions to the mental representation and attentional targeting of salient extrapersonal events.

              The syndrome of contralesional neglect reflects a lateralized disruption of spatial attention. In the human, the left hemisphere shifts attention predominantly in the contralateral hemispace and in a contraversive direction whereas the right hemisphere distributes attention more evenly, in both hemispaces and both directions. As a consequence of this asymmetry, severe contralesional neglect occurs almost exclusively after right hemisphere lesions. Patients with left neglect experience a loss of salience in the mental representation and conscious perception of the left side and display a reluctance to direct orientating and exploratory behaviours to the left. Neglect is distributed according to egocentric, allocentric, world-centred, and object-centred frames of reference. Neglected events can continue to exert an implicit influence on behaviour, indicating that the attentional filtering occurs at the level of an internalized representation rather than at the level of peripheral sensory input. The unilateral neglect syndrome is caused by a dysfunction of a large-scale neurocognitive network, the cortical epicentres of which are located in posterior parietal cortex, the frontal eye fields, and the cingulate gyrus. This network coordinates all aspects of spatial attention, regardless of the modality of input or output. It helps to compile a mental representation of extrapersonal events in terms of their motivational salience, and to generate 'kinetic strategies' so that the attentional focus can shift from one target to another.
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                Author and article information

                Journal
                Front Hum Neurosci
                Front Hum Neurosci
                Front. Hum. Neurosci.
                Frontiers in Human Neuroscience
                Frontiers Media S.A.
                1662-5161
                10 May 2013
                2013
                : 7
                : 187
                Affiliations
                [1] 1Department of Rehabilitation Medicine, West China Hospital, Sichuan University Chengdu, China
                [2] 2Institute for Disaster Management and Reconstruction, Sichuan University Chengdu, China
                [3] 3Department of Rehabilitation Sciences, The Hong Kong Polytechnic University Hong Kong
                [4] 4Department of Neurology, West China Hospital, Sichuan University Chengdu, China
                Author notes

                Edited by: Stefan Van Der Stigchel, Utrecht University, Netherlands

                Reviewed by: René Müri, University of Bern, Switzerland; Luciano Fasotti, Radboud University Nijmegen, Netherlands

                *Correspondence: Kenneth N. K. Fong, Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hung Hom, Hong Kong. e-mail: rsnkfong@ 123456polyu.edu.hk
                Article
                10.3389/fnhum.2013.00187
                3650319
                23675339
                55489453-28ea-4f4a-b84a-66b2c57e1ac6
                Copyright © 2013 Yang, Zhou, Chung, Li-Tsang and Fong.

                This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in other forums, provided the original authors and source are credited and subject to any copyright notices concerning any third-party graphics etc.

                History
                : 31 January 2013
                : 24 April 2013
                Page count
                Figures: 3, Tables: 5, Equations: 0, References: 67, Pages: 11, Words: 7341
                Categories
                Neuroscience
                Review Article

                Neurosciences
                systematic review,stroke,unilateral neglect,rehabilitation,behavioral inattention test

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